Iatrogenic bacterial meningitis (IBM) is a rare but serious complication of neuraxial procedures, such as spinal and epidural anesthesia or lumbar puncture. We report a case of a 46-year-old female who presented to the emergency department with bacterial meningitis after spinal anesthesia. We reviewthe existing literature outlining the pathogenesis, vector hypothesis, diagnosis, treatment, and prevention as they relate to IBM. We highlight the role of the emergency physician in the rapid diagnosis of this disease, and underscore the need for sterile technique when performing lumbar punctures.

Severe complications such as spinal epidural haematoma and an array of adverse neurological events leading to temporary or permanent disability have been ascribed to central neuraxial blocks. Infections (meningitis, abscesses), chemical injuries and very rarely cerebral ischaemia or haemorrhage, or both, have also been ascribed directly or indirectly to spinal and/or epidural anaesthesia. Some case reports, and very few retrospective studies, have focused their attention on the fact that central nerve blocks can cause, albeit rarely, permanent damage to the spinal cord or nerve roots, or both. The cause of this damage in many cases remains unclear. The attention of investigators and practitioners is focused both on understanding the causative mechanisms of such accidents and in identifying 'alarm events' that can arise during the administration of a central block, if any. We reviewed the international literature for the neurological complications of central neuraxial blocks to identify some events that, if they occurred during the block procedure, could be perceived as dangerous.

Background and objective: The aim of this prospective, randomized study was to compare the preparation and discharge times, the side-effects and patient satisfaction after gynaecological outpatient procedures performed using either spinal block or total intravenous anaesthesia with propofol and remifentanil.

Methods: With Ethics Committee approval and written informed consent, 40 healthy females scheduled for hysteroscopic ablation of endometrial neoplasm were randomly allocated to receive either a spinal block with bupivacaine 0.5% hyperbaric solution 10 mg (n = 20) or total intravenous anaesthesia with propofol and remifentanil (n = 20). Preparation and discharge times, as well as occurrence of untoward events and anaesthesiarelated costs, were recorded.

Results: The median (range) preparation time was 7 (7–10) min with general anaesthesia, and 11 (7–21) min with spinal block (P = 0.00005). No differences in discharge time from the postanaesthesia care unit and incidence of hypotension or bradycardia, or both, were reported between the two groups. Hospital discharge times were 156 (101–345) min after general anaesthesia and 296 (195–720) min after spinal anaesthesia (P = 0.0005). Acceptance of the anaesthesia technique was better after general (100%) than after spinal anaesthesia (75%) (P = 0.04). No differences in total costs were reported between spinal block (€155 (€117–€224)) and propofol-remifentanil general anaesthesia (€143 (€124–€203) (P = 0.125)).

Conclusions: Accurate titration of short-acting intravenous anaesthetic drugs such as propofol and remifentanil results in shorter preparation times and earlier home discharge after outpatient gynaecological procedures compared with spinal anaesthesia with hyperbaric bupivacaine 10 mg, with better patient acceptance and no increased costs.

Background and objective: The epidural and subarachnoid spaces should be identified at the first attempt, since multiple punctures increase the risk of postdural puncture headache, epidural haematoma and neural trauma. The study aimed to describe the predictors of successful neuraxial blocks at the first attempt.

Methods: After institutional Review Board approval, 1481 patients undergoing spinal or epidural anaesthesia were prospectively enrolled. For each block we recorded: gender, age, height, weight, body habitus, anatomical landmarks (palpability of the spinous processes), spinal anatomy, patient positioning, premedication, needle type and gauge, approach, spinal level of the block, and the provider’s level of experience. Retrieval of cerebrospinal fluid or loss of resistance to saline or air identified the subarachnoid and epidural spaces, respectively. The outcome variable was the first attempt success or failure (whether or not the needle was correctly located with one skin puncture and produced adequate surgical anaesthesia). Backward stepwise logistic regression tested its association with the other variables.

Results: The first-attempt rate of success was 61.51%. Independent predictors (Odds ratio, 95% confidence limits) were the quality of anatomical landmarks (1.92 (1.57; 2.35)), the provider’s level of experience (1.24 (1.15; 1.33)) and the adequacy of patient positioning (3.84 (2.84; 5.19)).

Conclusions: The successful location of the subarachnoid or the epidural space at the first attempt is influenced by the quality of patients’ anatomical landmarks, the adequacy of patient positioning and the provider’s level of experience.

Background and objective: Auditory impairment is among the lesser known complications of spinal analgesia. The aim of the present study was to determine the degree of vestibulocochlear dysfunction in patients undergoing spinal analgesia for lower abdominal surgery.

Methods: Eighty patients who had received spinal analgesia for lower abdominal surgery were studied. Males were undergoing inguinal herniorraphy and the females tubectomy. Audiograms were performed before operation and on the second and seventh postoperative days. Hearing levels were measured from 250 Hz-8 kHz. In Group 1 (n = 40) a 22-gauge, cutting type of spinal needle (Howard Jones) was used. In Group 2 (n = 40) a 25-gauge, non-cutting spinal needle (Whitacre) was used.

Results: Hearing loss ' 10 dB was noticed in three patients in Group 1 and none in Group 2. The mean hearing level was more reduced in Group 1 patients.

Conclusions: Use of cutting type spinal needle is associated with a greater decrease in mean hearing levels compared to the non-cutting type.

Background and objective: To evaluate the efficacy and optimal dose of prophylactic intravenous ephedrine for the prevention of maternal hypotension associated with spinal anaesthesia for Caesarean section.

Methods: After patients had received an intravenous preload of 0.5 L of lactated Ringer's solution, spinal anaesthesia was administered in the sitting position with hyperbaric bupivacaine 2.5 mL 0.5% combined with 25 μg fentanyl. A total of 68 patients were randomized to receive a simultaneous 2 mL bolus intravenously of either 0.9% saline (Group C, n = 20), ephedrine 6 mg (Group E-6, n = 24), or ephedrine 12 mg (Group E-12, n = 22). Further rescue boluses of ephedrine 6 mg were given if systolic arterial pressure fell to below 90 mmHg, greater than 30% below baseline, or if symptoms suggestive of hypotension were reported.

Results: There was a significantly higher incidence of hypotension in Group C (60% patients) compared to Group E-12 (27%), but not in Group E-6 (50%). The 95% Confidence Interval for the difference in proportions between Groups C and E-12 was 6-60%, P < 0.05. Fewer rescue boluses of ephedrine were required in Group E-12 compared with Group C (1.8 ± 1.2 vs. 3.3 ± 2.1, P < 0.05). There were no significant differences in the incidence of maternal nausea or vomiting, or of neonatal acidaemia between groups.

Conclusion: A prophylactic bolus of ephedrine 12 mg intravenously given at the time of intrathecal block, plus rescue boluses, leads to a lower incidence of hypotension following spinal anaesthesia for elective Caesarean section compared to intravenous rescue boluses alone.

A 6-months pregnant woman suffering from severe tetanus was successfully treated with intrathecal baclofen. She delivered a premature but healthy neo-nate, and was safely discharged home 40 days after the onset of symptoms of tetanus. Specific aspects of intrathecal baclofen therapy in the pregnant woman are discussed.

This study was designed to determine whether low doses of intrathecal morphine still result in itching and it evaluates the outcome of a standardized treatment using promethazine and – for intractable itch – naloxone. Patients (n = 143) scheduled for total hip surgery were allocated to four groups (in a double blind manner) with bupivacaine 20 mg in 4 mL but different doses of intrathecal morphine: Group I, 0.025 mg, Group II, 0.05 mg, Group III, 0.1 mg and Group IV, 0.2 mg. The presence or absence of itching was noted every three hours for a 24-h period. When required, standardized treatment was provided. The incidence of itching was: Group I: 14.3%; Group II: 21.6%; Group III: 48.6%; and, Group IV: 61.7%. Itch was treated by administering promethazine intramuscularly in 2.9% (Group I); 8.1% (Group II); 10.8% (Group III), and 8.9% (Group IV), respectively. Only in group IV there was a single patient who needed naloxone to treat itching. The incidence and severity of itching is a dose-related side-effect in the dose range of 0.025–0.2 mg of intrathecal morphine. Itching still occurs after the low doses of intrathecal morphine, but symptoms vanish after promethazine 25 mg intramuscularly.

A review was undertaken of all 190 patients who were referred over 7 years, from 1991 to 1997 inclusive, for an epidural blood patch as a treatment for headache after dural puncture. The patterns of referral and symptoms, the distributions of age and gender and the effectiveness of the blood patch were examined. Most of the referrals (n=153) were after deliberate diagnostic dural puncture in neurology and neuroradiology, with a minority (n=28) used for anaesthesia and obstetrics, which were mostly inadvertent. Another nine cases were related to placement of an intrathecal catheter. The numbers of referrals per year reached a maximum in 1995 before falling again, a curious inverse relation to the number of invasive neuro-radiological diagnostic procedures. Most of the patients were between 30 and 50-years-old, with 25 younger than 30 and 14 older than 60. Women accounted for 70% of the referrals for headache, although the gender ratio amongst patients subjected to at risk procedures appeared closer to 50:50. Neckache accompanied the headache in 85% of cases, auditory problems were volunteered by three patients and one patient had diplopia for 6 weeks. Of the 190 patients who were referred, 186 received at least one patch, the symptoms in the remaining four being too mild or atypical to warrant blood patch treatment. This provided initial relief in all but two patients, one of whom received a further epidural blood patch with no effect. There was sustained relief of symptoms in 136 and a partial relapse in 38 patients, which resolved without needing any further blood patch. A second patch was provided for seven patients and a third for three patients, of whom two were cured. Of the patients who needed more than one blood patch, nine were after inadvertent dural puncture with a Tuohy needle and, of these patients, six were in labour. A total of 200 patches were provided in all for the 186 patients and all but three patients had a satisfactory outcome. Epidural blood patches are effective in treating headache after dural puncture, but less successful than is commonly believed, especially after inadvertent dural taps. A relapse after treatment does not always require a second patch. Specialities other than anaesthesia seemed reluctant to accept the benefits in both cost and comfort of using needles of improved design for dural puncture.

The increasing use of ambulatory surgery requires methods of anaesthesia that allow patients to be discharged soon after the operation is completed. Spinal anaesthesia is usually simple and quick, and the incidence of post-spinal headache has been reduced by using non-cutting small-gauge needles. Limiting the spread of spinal anaesthesia, as long as it still provides analgesia for surgery, should reduce the haemodynamic effects and speed recovery. Restricted spinal anaesthesia, intended to be unilateral using 0.18% hypobaric bupivacaine via a 25G or 27G Whitacre unidirectional needle, was compared with epidural anaesthesia (using a mixture of lignocaine and prilocaine) in 64 matched-pair patients undergoing ambulatory arthroscopy. Motor blockade, assessed for the specific myotomes L2 to S1, was significantly more unilateral in the spinal group. Two patients in the spinal group and nine patients in the epidural group were treated for hypotension (P < 0.05). One patient in the spinal group developed a post-spinal headache. One patient in the epidural group rated the anaesthesia poor.

We describe a case of transient neurological deficit that occurred after unilateral spinal anaesthesia with 8 mg of 1% hyperbaric bupivacaine slowly injected through a 25-gauge pencil-point spinal needle. The surgery and anaesthesia were uneventful, but 3 days after surgery, the patient reported an area of hypoaesthesia over L3–L4 dermatomes of the leg which had been operated on (loss of pinprick sensation) without reduction in muscular strength. Sensation in this area returned to normal over the following 2 weeks. Prospective multicentre studies with a large population and a long follow-up should be performed in order to evaluate the incidence of this unusual side effect. However, we suggest that a low solution concentration should be preferred for unilateral spinal anaesthesia with a hyperbaric anaesthetic solution (if pencil-point needle and slow injection rate are employed), in order to minimize the risk of a localized high peak anaesthetic concentration, which might lead to a transient neurological deficit.

The cause of hearing loss after spinal anaesthesia is unknown. Up until now, the only factor studied has been the effect of the diameter of the spinal needle on post-operative sensorineural hearing loss. The aim of this study was to describe this hearing loss and to investigate other factors influencing the degree of hearing loss. Two groups of 22 similar patients were studied: one group received 6 mL prilocaine 2%; and the other received 3 mL bupivacaine 0.5%. Patients given prilocaine were more likely to develop hearing loss (10 out of 22) than those given bupivacaine (4 out of 22) (P<0.05). The average hearing loss for speech frequencies was about 10 dB after prilocaine and 15 dB after bupivacaine. None of the patients complained of subjective hearing loss. Long-term follow-up of the patients was not possible.

Major knee surgery is associated with moderate or severe post-operative pain. Intrathecal morphine and continuous femoral 3-in-1 block were compared prospectively in 40 patients for pain after major knee surgery under spinal anaesthesia, with 4 mL isobaric 0.5% bupivacaine. In a random order, 20 patients received preservative free morphine 0.3 mg mixed with spinal bupivacaine. In 20 patients, following spinal anaesthesia with only bupivacaine, femoral 3-in-1 block was performed post-operatively with 0.5% bupivacaine 2 mg kg−1. The block was continued via a catheter with 0.25% bupivacaine 0.1 mL h−1 kg−1 until the next morning (24 h after induction of spinal anaesthesia). Intramuscular oxycodone was given as a rescue analgesic in all patients. Two patients from the femoral group were excluded due to technical failure. Three patients in the morphine group and one patient in the femoral group did not need any additional oxycodone. In the morphine group on average 2.8 (range 0–7) and in the femoral group 3.2 (0–5) additional doses of oxycodone were needed during the 24 h observation period. The mean pain scores were significantly lower in the morphine group at 9 and 12 h into the 24-h trial. Itching was seen only in the morphine group (40% of the patients). Other side effects were similar in the two groups. All patients were satisfied with their pain therapy. Both intrathecal morphine and femoral 3-in-1 block alone were insufficient for the treatment of severe pain after major knee surgery.

Cardiovascular responses after epidural alkalinized lignocaine and subarachnoid hyperbaric bupivacaine administration were studied using a non-invasive cardiac output measurement in 32 ASA Grade I–II patients undergoing orthopaedic leg surgery (hip hemi-arthroplasty or Ender nailing). All patients achieved adequate surgical anaesthesia. The block onset time was faster (P = 0.003), and the range of final sensory level wider (P = 0.006) in patients receiving spinal anaesthesia compared with the epidural group. Diastolic arterial pressure was significantly reduced when compared with base-line (P = 0.002) only in the spinal group. No significant changes in stroke volume, systemic vascular resistance or left ventricular stroke work were observed in either group. Heart rate and cardiac index were significantly reduced in the spinal group when compared both with base-line (P = 0.002; P = 0.04) and the epidural group (P = 0.001; P = 0.006). The results demonstrated that the block onset time and the cardiovascular effects produced by lumbar epidural anaesthesia, with alkalinized solutions, remain less than after spinal anaesthesia involving the same segments.